الفهرس 
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Abstract
Summary
Breast cancer is the most common malignancy among
women and the fifth cause of death due to cancer both in the
less developed (LDCs) and more developed (MDCs) countries
worldwide.
The lymphatic drainage of the breast is of great
importance in the spread of malignant disease of the breast.
The primary route of lymphatic drainage of the breast is
through the axillary lymph node groups Therefore, it is
essential that the clinician understand the anatomy of the
grouping of lymph nodes within the axilla. More than 75% of
the lymph from the breast passes to the axillary lymph nodes.
Most of the remainder of the lymph passes to the parasternal
nodes.
The important muscles in the region of the breast are the
pectoralis major and minor, serratus anterior, and latissimus
dorsi muscles, as well as the aponeurosis of the external
oblique and rectus abdominis muscle.
Breast carcinomas include; ductal, lobular, and special
types as inflammatory carcinoma, Paget’s disease & mucinous
carcinoma.
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Management of breast cancer depends on three main
components; diagnosis of breast cancer, the required
investigations and the relevant treatment according to staging.
The management of patients with breast cancer has
evolved over the past couple of decades as a result of a better
understanding of the biologic behavior of breast cancer,
advances in adjuvant chemotherapy and hormonal therapy,
advances in radiographic detection of early-stage breast cancer,
and the implementation of breast conservation therapy and
sentinel lymph node biopsy.
All women over the age of 20 should be advised to
examine their breasts monthly. Premenopausal women should
perform their examination 7-8 days after their menstrual
period. The breasts should be inspected initially while standing
in front of a mirror with their hands sides, overhead and press
firmly on their hips to contract the pectoralis muscles. Masses,
asymmetry of breasts, and slight dimpling of the skin may be
apparent as a result of these maneuvers.
Routine screening mammography and increased breast
cancer awareness are primarily responsible for the trend
towards earlier diagnosis. Although radical and modified
radical mastectomies have been the mainstay treatment for
early-stage breast cancer for decades, breast-conserving
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therapy has recently become the preferred method of treatment
for appropriate patients with early-stage breast cancer.
Guidelines from the American College of Radiology and
the American College of Surgeons provide a general
framework for identifying and managing BCT candidates.
The goal of breast conserving surgery is to achieve a low
rate of local recurrence while preserving the cosmetic outcome.
Segmental mastectomy, partial mastectomy and lumpectomy
are the most common forms of breast conserving surgery
internationally.
The axillary lymph node status represents one of the
most important prognostic factors in breast cancer patients and
determines among others subsequent adjuvant treatment. The
percentage of node positive patients who benefit from routine
axillary lymph node dissection (ALND) is constantly
decreasing as breast cancer is increasingly detected at an early
stage.
Breast reconstruction has become an integral aspect of
breast cancer management. The timing of breast reconstruction
after mastectomy involves many factors that are important
when choosing between immediate and delayed reconstruction.
Immediate reconstruction has positive psychological
implications on patients by reducing the physical mutilation in
oppose to delayed reconstruction. In addition, practice patterns
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have gradually trended towards more immediate
reconstructions for non-irradiated patients owing to superior
aesthetic outcomes, more facilitating recoveries, and the ability
to maintain an equivalent oncologic outcome.
The primary goal of breast reconstruction is to create a
long lasting, naturally appearing breast after the treatment of
breast cancer. This goal should be achieved with the least
possible morbidity at the donor site.
Recent techniques in breast reconstruction are broadly
divided into autologous tissue reconstruction, non-autologous
reconstruction or a combination of both.
Autologous tissue breast reconstruction can generally be
grouped into three main categories: local tissue rearrangement
with composite breast flaps, reduction mammaplasty, and
transfer of remote tissue in the form of a vascularised regional
or distant flap.
Non-autologous or implant- based techniques are a
simple and effective method of breast reconstruction, but they
may not be suitable for all patients, particularly those who need
or have had radiotherapy. Although autologous methods are
more surgically demanding, they yield better aesthetic results
than non-autologous methods.
Oncoplastic surgiers include: Excision of the cancer with
adequately wide free margins to achieve loco regional control,
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Immediate remodeling of the defect to improve the cosmetic
result, Contralateral breast symmetrization and reconstruction of
the nipple -areola complex (NAC), when needed and Immediate
and late reconstruction after mastectomy.
Breast tissue defects following tumor resection may be
prevented in some patients following simple basic surgical
guidelines (e.g. mobilization of the gland, NAC recentralization,
choice of incision, mirror biopsies) at the time
of primary surgery.
Oncoplastic surgery can be performed using either
volume displacement or volume replacement techniques.
Volume displacement techniques allow for reconstruction of
the resection defect by transposing tissue from elsewhere in the
breast, these techniques include a batwing mastopexy,
lumpectomy, radial segmental lumpectomy, donut mastopexy
lumpectomy and reduction mastopexy lumpectomy.
In volume replacement techniques, local tissue such as a
latissimus dorsi flap can be used to fill the defect and may be
preferable when volume displacement techniques are unable to
provide a satisfactory result with regard to shape and size of
the breast particularly if the patient is unwilling to undergo
surgery in the opposite breast.
Nipple- areola complex reconstruction is an integral
component of breast reconstruction which transforms the
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reconstructed breast mound into a more natural and pleasing
breast. It is typically performed three months after the mound
has been successfully reconstructed by the use of local flaps
with or without skin grafts or as a composite free nipple graft
from the contralateral breast. Areolar tattooing and secondary
procedures to improve nipple height can also be done at a later
date.
Symmetry is one of the most important aims in breast
reconstruction. This will further improve the overall outcome
and patient satisfaction. Two types of equality must be
considered: equality of volume and equality of shape. These
can be achieved by either a reduction or augmentation
mammaplasty procedure to the contralateral breast.
Complications of breast reconstruction are not amongst
patients’ expectations or in the surgeon’s interest. However,
like scarring, they can occur. Minor complications can delay
recovery or require further treatment and can be the cause of
severe frustration for the patient and her family. The
occurrence of complete failure, like total flap necrosis or the
need to remove a silicon implant due to infection is relatively
uncommon.
Various oncoplastic techniques for breast reconstruction
are available, and the decision of the technique used is based
on local tissue demands and the preferences of both surgeon
and patient to achieve the best possible results.